Predicting Length of Stay Following Radical Nephrectomy Using the National Surgical Quality Improvement Program Database.

PURPOSE: Length of stay is frequently used to measure the quality of health care, although its predictors are not well studied in urology. We created a predictive model of length of stay after nephrectomy, focusing on preoperative variables. MATERIALS AND METHODS: We used the NSQIP database to evaluate patients older than 18 years who underwent nephrectomy without concomitant procedures from 2007 to 2011. Preoperative factors analyzed for univariate significance in relation to actual length of stay were then included in a multivariable linear regression model. Backward elimination of nonsignificant variables resulted in a final model that was validated in an institutional external patient cohort. RESULTS: Of the 1,527 patients in the NSQIP database 864 were included in the training cohort after exclusions for concomitant procedures or lack of data. Median length of stay was 3 days in the training and validation sets. Univariate analysis revealed 27 significant variables. Backward selection left a final model including the variables age, laparoscopic vs open approach, and preoperative hematocrit and albumin. For every additional year in age, point decrease in hematocrit and point decrease in albumin the length of stay lengthened by a factor of 0.7%, 2.5% and 17.7%, respectively. If an open approach was performed, length of stay increased by 61%. The R(2) value was 0.256. The model was validated in a 427 patient external cohort, which yielded an R(2) value of 0.214. CONCLUSIONS: Age, preoperative hematocrit, preoperative albumin and approach have significant effects on length of stay for patients undergoing nephrectomy. Similar predictive models could prove useful in patient education as well as quality assessment.

Extramammary Paget's disease in males: survival outcomes in 495 patients.

BACKGROUND: Extramammary Paget's disease (EMPD) is a rare intraepithelial malignancy with poorly described outcomes. EMPD in men is primarily found in the perianal and penoscrotal areas. We assessed incidence and time trends of EMPD in men as well as extent and predictors of survival using the Surveillance, Epidemiology, and End Results (SEER) program. METHODS: The data from 18 SEER registries were queried for men diagnosed with EMPD from 1973 to 2009. Cases were categorized by primary skin location: perianal, penoscrotal, and other truncal. Additional data included age, race, presence of another cancer, tumor stage, and treatment (surgery, radiation, combination). Kaplan-Meier, univariate, and multivariate Cox regression analyses were conducted. RESULTS: Incidence rates of EMPD in men have been increasing with an annual percent change of +3.2 % (p < .0002) since 1978. Incidence of EMPD in blacks was nearly four times lower (p = .0003) and in Asians/Pacific islanders four times higher (p < .0001), relative to whites. Overall survival among 495 patients was 60.2 % at 120 months postdiagnosis. On multivariate analysis, significant factors negatively impacting survival were primary site in the perianal region compared to penoscrotal and truncal lesions (both p < .001), age older than 75 years (p < .001), and presence of distant versus localized disease (p = .018). Survival did not differ by race or presence of additional cancer. CONCLUSIONS: Survival in men with EMPD is lower among those with distant disease and primary tumors located in the perianal region. The reasons for increasing EMPD incidence over time and for the racial disparities in disease occurrence require further study.

External validation of the modified Glasgow prognostic score for renal cancer.

PURPOSE: The modified Glasgow prognostic Score (mGPS) incorporates C-reactive protein and albumin as a clinically useful marker of tumor behavior. The ability of the mGPS to predict metastasis in localized renal cell carcinoma (RCC) remains unknown in an external validation cohort. PATIENTS AND METHODS: Patients with clinically localized clear cell RCC were followed for 1 year post-operatively. Metastases were identified radiologically. Patients were categorized by mGPS score as low-risk (mGPS = 0 points), intermediate-risk (mGPS = 1 point) and high-risk (mGPS = 2 points). Univariate, Kaplan-Meier and multivariate Cox regression analyses examined Recurrence -free survival (RFS) across patient and disease characteristics. RESULTS: Of the 129 patients in this study, 23.3% developed metastases. Of low, intermediate and high risk patients, 10.1%, 38.9% and 89.9% recurred during the study. After accounting for various patient and tumor characteristics in multivariate analysis including stage and grade, only mGPS was significantly associated with RFS. Compared with low-risk patients, intermediate- and high-risk patients experienced a 4-fold (hazard ratios [HR]: 4.035, 95% confidence interval [CI]: 1.312-12.415, P = 0.015) and 7-fold (HR: 7.012, 95% CI: 2.126-23.123 P < 0.001) risk of metastasis, respectively. CONCLUSIONS: mGPS is a robust predictor of metastasis following potentially curative nephrectomy for localized RCC. Clinicians may consider mGPS as an adjunct to identify high-risk patients for possible enrollment into clinical trials or for patient counseling.

Scrotal cancer survival is influenced by histology: a SEER study.

INTRODUCTION: Due to the scrotum's multiple layers of different tissues, scrotal cancer can present with several unique histologies. Historically, outcome arising from these different sources has been historically aggregated together. However, it remains unclear whether survival differs by histology of scrotal cancer. METHODS: We queried the seventeen registries of the Surveillance, Epidemiology, and End Results database for patients diagnosed with primary scrotal cancer from 1973 to 2006. Patients were initially grouped by the following histologies: basal cell carcinoma, Extramammary Paget's Disease (EMPD), sarcoma, melanoma, squamous cell carcinoma, and adnexal skin tumors. For some analyses, the former three histologies were reclassified as Low-Risk scrotal cancer and the latter three histologies as High-Risk scrotal cancer. Kaplan-Meier survival analyses were conducted to assess the impact of histology on overall survival (OS). RESULTS: The cohort consisted of 766 patients. Median (95% CI) OSs by histologies were basal cell carcinoma--143 (116-180), EMPD--165 (139-190), sarcoma--180 (141-219), melanoma--136 (70-203), squamous cell carcinoma--115 (97-133), and adnexal skin tumors--114 (55-174). Patients with Low-Risk scrotal cancer experienced a median (95% CI) OS of 166 (145-188) months, while patients with High-Risk scrotal cancer experienced a median (95% CI) OS of 118 (101-135) months. CONCLUSIONS: Survival of scrotal cancer depends on tumor histology. Classification of histologies into Low and High Risk can be clinically useful for counseling and clinical decisions.

Posterior lumbar vein off the retrohepatic inferior vena cava: a novel anatomical variant with surgical implications.

PURPOSE: Resection of tumors involving the inferior vena cava requires vascular control of posteriorly draining lumbar veins to ensure a bloodless field. Surgical texts and atlases assert that lumbar veins do not insert into the inferior vena cava superior to the renal hilum. However, at our institution we have encountered patients undergoing inferior vena cava tumor thrombectomy who have a posterior lumbar vein cephalad to the renal veins. Since this represents an unrecognized source of hemorrhage, we investigated the frequency of a superior lumbar vein in cadaveric dissection. MATERIALS AND METHODS: Retroperitoneal cadaveric dissection of the inferior vena cava was done to assess the frequency of a lumbar vein draining into the inferior vena cava cephalad to the renal veins. RESULTS: Of the 49 cadaveric dissections performed 19 (38.8%) showed a single posterior lumbar vein between the diaphragm and the renal hilum. Of these 19 cadavers 15 (78.9%) were male. This vein was located an average ± SD of 7.4 ± 0.6 cm cephalad to the right renal vein and it was 3.7 ± 1.6 cm in diameter. In all cadavers this vein inserted within 30 degrees to the left or right of the posterior (also termed dorsal) aspect of the inferior vena cava. CONCLUSIONS: The identification of a lumbar vein between the renal hilum and the diaphragm represents an important anatomical variant that occurs in a significant percent of individuals. Surgeons will benefit from the knowledge of this variant of inferior vena cava vasculature and should anticipate the presence of this vein to prevent unnecessary morbidity and mortality secondary to unexpected hemorrhage, particularly in male patients.

Exercise is associated with better erectile function in men under 40 as evaluated by the International Index of Erectile Function.

INTRODUCTION: Studies have shown an association between erectile dysfunction and sedentary lifestyle in middle-aged men, with a direct correlation between increased physical activity and improved erectile function. Whether or not this relationship is present in young, healthy men has yet to be demonstrated. AIM: The aim of this study was to assess the association between physical activity and erectile function in young, healthy men. MAIN OUTCOME MEASURES: The primary end points for our study were: (i) differences in baseline scores of greater than one point per question for the International Index of Erectile Function (IIEF); (ii) differences in baseline scores of greater than one point per question for each domain of the IIEF; (iii) exercise energy expenditure; and (iv) predictors of dysfunction as seen on the IIEF. METHODS: The participants were men between the ages of 18 and 40 years old at an academic urology practice. Patients self-administered the Paffenbarger Physical Activity Questionnaire and the IIEF. Patients were stratified by physical activity into two groups: a sedentary group (≤1,400 calories/week) and an active group (>1,400 calories/week). Men presenting for the primary reason of erectile dysfunction or Peyronie's disease were excluded. RESULTS: Seventy-eight patients had complete information in this study: 27 patients (34.6%) in the sedentary group (≤1,400 kcal/week) and 51 patients (65.4%) in the active group (>1,400 kcal/week). Sedentary lifestyle was associated with increased dysfunction in the following domains of the IIEF: erectile function (44.4% vs. 21.6%, P = 0.04), orgasm function (44.4% vs. 17.7%, P = 0.01), intercourse satisfaction (59.3% vs. 35.3%, P = 0.04), and overall satisfaction (63.0% vs. 35.3%, P = 0.02). There was a trend toward more dysfunction in the sedentary group for total score on the IIEF (44.4% vs. 23.5%, P = 0.057), while sexual desire domain scores were similar in both groups (51.9% vs. 41.2%, P = 0.37). CONCLUSIONS: We have demonstrated that increased physical activity is associated with better sexual function measured by a validated questionnaire in a young, healthy population. Further studies are needed on the long-term effects of exercise, or lack thereof, on erectile function as these men age.

Peak window of suicides occurs within the first month of diagnosis: implications for clinical oncology.

OBJECTIVE: A diagnosis of cancer can provoke painful emotional reactions and possibly suicidal thoughts in a patient. Consequently, cancer patients carry a twofold increased lifetime risk of suicide. This risk is much higher within 1 year of diagnosis. However, it remains largely unknown whether suicide frequency remains constant within the first year. Therefore, we sought to characterize the distribution of suicides in order to potentially identify a clinically important window of peak suicide risk. METHODS: We queried the Surveillance, Epidemiology, and End Results (SEER) database for cancer patients 20 + years old with diagnosed with a single malignancy from 1973 to 2005 and known cause of death, including whether a patient committed suicide. Initial frequency analysis was performed to identify the period of maximum suicide risk. One-way ANOVA was performed to assess the relationship between year of diagnosis and suicide completions within 1 month of diagnosis. RESULTS: The cohort consisted of 3,678,868 patients. Of the total cohort, 0.2% (5875 patients) committed suicide, 36% (2111 patients) within 1 year of diagnosis. One in three (701 of the patients) who committed suicide in the first year did so within 1 month of diagnosis. No change in this distribution occurred over time. CONCLUSIONS: Cancer patients carry an increased risk of suicide. However, this risk peaks with the month following diagnosis. Clinicians should be aware of this increased risk and include assessments of mood state and suicidality at the time of initial diagnosis of the malignancy and be prepared to provide referral to mental health treatment providers.

IPSS quality of life question: a possible indicator of depression among patients with lower urinary tract symptoms.

INTRODUCTION: Depression and benign prostatic hyperplasia (BPH) are prevalent, especially in older patient populations. Emerging data suggest potential interactions between depression and BPH. We sought to assess whether the questions of the International Prostate Symptom Score (IPSS), specifically the quality of life (QoL) question, predict depression. MATERIALS AND METHODS: We asked 541 consecutive male patients over the age of 40 in a tertiary care clinic to self-administer the IPSS QoL score and the Geriatric Depression Scale (GDS), a validated screening tool for depression. Receiver operating characteristics (ROC) curves were depicted and used to determine the area under the curve (AUC) and relative sensitivity and specificity of the individual questions of the IPSS relative to the GDS. RESULTS: Of the cohort, 17.2 percent screened positive for depression. More than half (54.7%) of nondepressed patients had a QoL score of 0-2, while a similar number of depressed patients (50.8%) had a QoL score of 5 or 6. The QoL question of the IPSS exhibited an AUC (95% CI, p value) of 0.735 (0.669-0.800, p < 0.001). A cut-off of QoL scores > 5 exhibited the highest specificity (93.1%)while a cut off of QoL scores > 1 exhibited a sensitivity of 90.0%. CONCLUSIONS: Future studies should validate these findings and shed further light on this tool's clinical utility. Pending this future validation, patients with a score of 6 could be considered for further mental health evaluation.

Expression of C-reactive protein and cyclooxygenase enzyme-2 in clear cell renal cell carcinoma: correlation with pathological parameters in 110 patients.

C-reactive protein is produced in response to cytokines such as interleukin (IL)-6. It is known that increased plasma IL-6 levels induce increased hepatic and intratumoral production of C-reactive protein. Cyclooxygenase enzyme-2 is induced by various stimuli, including inflammation and various growth factors. Expression of these two markers has not been well studied in clear cell renal cell carcinoma. The objective of this study is to correlate the expression of C-reactive protein and cyclooxygenase enzyme-2 in clear cell renal cell carcinoma with pathologic parameters. A search of the surgical pathology and consultation files at our institution was performed for nephrectomy specimens with clear cell renal cell carcinoma from 2007 to 2008. Immunohistochemical stains for C-reactive protein and cyclooxygenase enzyme-2 were performed. Staining intensity was graded as 0, 1+, 2+, and 3+. The staining intensity was then correlated with pathologic stage and Fuhrman nuclear grade for each case. A total of 110 cases were identified. Strong expression of C-reactive protein was associated with higher Fuhrman nuclear grade and pathologic stage, and the strength of correlation was statistically significant (p = 0.01 and p = 0.001), respectively. However, cyclooxygenase enzyme-2 expression did not show statistically significant correlation with both pathologic stage and Fuhrman nuclear grade (p = 0.1 and p = 0.15), respectively. To our knowledge, this is the largest study to date correlating the expression of both C-reactive protein and cyclooxygenase enzyme-2 in tissue with pathologic parameters in patients with clear cell renal cell carcinoma, which could have significant prognostic and therapeutic implications.

Trichoblastoma of the eyelid.

A 50-year-old woman developed a slow-growing tumor of the right medial canthus. Excisional biopsy and histologic examination showed a trichoblastoma. This nodule was excised using Mohs micrographic and reconstructive surgery. Trichoblastoma is a rare, slow-growing neoplasm derived from the hair follicle. Though rarely undergoing malignant transformation, these nodules histologically resemble basal cell carcinoma and generally require complete excision.

C-reactive protein may represent sensitive measure of renal cell carcinoma metastasis.

A patient with localized kidney cancer underwent potentially curative nephrectomy. Routinely post-operative serum C-Reactive Protein (CRP) values were measured. At 25 months post-operatively, lung imaging suggested possible metastasis. However, CRP levels remained at baseline. Subsequent resection revealed a benign mass. CRP values have been shown to carry prognostic significance for overall and disease free survival. This case suggests a novel use for CRP: a sensitive biomarker of disease recurrence and metastasis.

Radical nephrectomy via epidural-only anesthesia.

We present what we believe is, to the best of our knowledge, the first report of open radical nephrectomy performed under epidural-only anesthesia. Our patient had localized renal cell carcinoma requiring open nephrectomy, but he also had comorbid emphysema that precluded general anesthesia. Epidural anesthesia, which bypassed the pulmonary system, allowed us to perform the surgery.

Multimedia version of a standard medical questionnaire improves patient understanding across all literacy levels.

PURPOSE: Low health literacy is a significant problem in the United States. At the same time written screening tools such as the American Urological Association symptom score are used more frequently at hospitals and clinics. We previously reported that many patients do not fully understand this tool and often provide inaccurate information. To combat this problem we developed a novel multimedia version of the American Urological Association symptom score. MATERIALS AND METHODS: In this randomized, controlled trial we divided 232 patients into a control arm that self-administered the traditional written version of the symptom score and an experimental arm that self-administered the new multimedia version. Patients in each arm were later administered the tool a second time by an interviewer for comparison. Using multivariate analysis we measured disagreement between the self-administered and interviewer administered scores, and compared the 2 arms. RESULTS: Patients assigned the written and the multimedia version showed an average error of 3.48 and 1.97, respectively (p <0.001), for a 43% decrease. Improvement was noted regardless of patient literacy. Errors by patients with low and high literacy decreased from 4.55 to 2.24 and 3.10 to 1.86 (p = 0.03 and <0.001, respectively). CONCLUSIONS: As a model, the American Urological Association symptom score multimedia version represents an exciting opportunity to improve many other written screening tools since it increased understanding and decreased scoring errors across all literacy levels, possibly allowing physicians to treat patients more effectively.

Assessment of the performance of the American Urological Association symptom score in 2 distinct patient populations.

PURPOSE: Recent research suggests that low education and illiteracy may drive misunderstanding of the American Urological Association Symptom Score, a key tool in the American Urological Association benign prostatic hyperplasia guidelines. It is unclear whether misunderstanding is confined to patients of low socioeconomic status. Therefore, we reevaluated the prevalence and impact of this misunderstanding in a county vs university hospital population. MATERIALS AND METHODS: This prospective study involved 407 patients from a county hospital and a university hospital who completed the American Urological Association Symptom Score as self-administered and then as interviewer administered. Responses were compared by calculating correlation coefficients and weighted kappa statistics to assess patient understanding of the American Urological Association Symptom Score. Multivariate logistic regression analyses were used to examine the association between patient characteristics and poor understanding of the American Urological Association Symptom Score. RESULTS: Of the patients 72% understood all 7 American Urological Association Symptom Score questions. Of the measured demographic variables only education level significantly affected this understanding. Compared to patients with more than 12 years of education county hospital patients with less than 9 years of education were 57.06 times more likely to misunderstand the American Urological Association Symptom Score (95% CI 14.32-329.34) while university hospital patients with less than 9 years of education were 38.27 times more likely to misunderstand the American Urological Association Symptom Score (95% CI 1.69-867.83). Of county hospital patients 31% and of university hospital patients 21% significantly misrepresented their symptom severity according to current guidelines. CONCLUSIONS: Patients with low education regardless of location are more likely to misunderstand the American Urological Association Symptom Score, misrepresent their symptoms and, therefore, receive inappropriate treatment.

Patient misunderstanding of the individual questions of the American Urological Association symptom score.

PURPOSE: Lower urinary tract symptoms are often assessed using the American Urological Association symptom score. However, some patients may experience difficulty completing the AUA questionnaire. We hypothesized that certain individual questions may generate more misunderstanding than others. MATERIALS AND METHODS: This study involved patients at 2 hospitals who completed the American Urological Association symptom score twice, that is 1) self-administered and 2) physician assisted. Analyses compared self-reported and physician obtained responses to each individual question. One-way ANOVA with the Tukey HSD post hoc test was done to assess whether mean disagreements between self-reported and physician administered American Urological Association symptom scores differed significantly by patient education level. RESULTS: The study group consisted of 998 patients. For each symptom score question we found an inverse relationship between education level and symptom misrepresentation. This discrepancy was the largest for questions on frequency (question 2) and urgency (question 4), which are related to irritative symptoms. Mean misrepresentation of the total American Urological Association symptom score was 2.42 and 5.33 for patients with greater than 12 and fewer than 9 years of education, respectively (p <0.001). Of patients with more than 12 years of education 28% misreported their symptoms by 4 points or greater and 1% misreported them by 10 points or greater, while 58% with fewer than 9 years of education misreported their total score by 4 points or greater and 21% misreported it by greater than 10 points. CONCLUSIONS: While the American Urological Association symptom score is a useful tool for the rapid diagnosis of benign prostatic hyperplasia, patients with low education misrepresent their scores more often and to a higher degree, possibly predisposing them to inappropriate care.

Determination of the formal reduction potential of Lumbricus terrestris hemoglobin using thin layer spectroelectrochemistry.

The formal reduction potential (Eo') of Lumbricus terrestris hemoglobin was determined using thin layer spectroelectrochemistry as 0.073 (+/-0.005) V vs Ag/AgCl (0.281 V vs SHE, standard hydrogen electrode). Nernst plots of Lumbricus terrestris hemoglobin with tris-bipyridinecobalt(II) as a mediator titrant have similar linear slopes as Nernst plots of horse heart myoglobin with hexaamineruthenium(II) as a mediator titrant.

Numeracy among trainees: are we preparing physicians for evidence-based medicine?

INTRODUCTION: In the era of evidence-based medicine, all physicians who communicate with patients need numerical literacy (numeracy). Single-institution studies suggest imperfect numeracy among medical students. Therefore, we sought to examine numeracy and understanding of risk analysis among medical students and surgical residents at several institutions. METHODS: Following a validated 3-item numeracy questionnaire, 308 medical students and 50 surgical residents from 4 institutions were asked whether they would recommend adjuvant chemotherapy for a patient based on presented survival data. Main outcome measures included numeracy, understanding of risk with a question requiring simple calculation of risk reduction, and confidence in understanding risk reduction using a Likert score (0 = no confidence and 7 = complete confidence). Binary logistic regression analysis identified predictors of misunderstanding of risk and Pearson correlation coefficients measured differences in confidence by level of training and numeracy. RESULTS: Students across institutions did not differ demographically and were grouped by educational level. Of all participants, 69.0% had perfect basic numeracy (score = 3), with no significant difference in numeracy across training levels (p = 0.433). Mean (standard deviation) confidence in recommending treatment increased from 4.5 (1.6) for first-year medical students to 4.8 (1.1) for fourth-year medical students, and 4.9 (1.5) for surgical residents (p = 0.580). Controlling for other demographics, poorly numerate students had a 7-fold increased likelihood (odds ratio: 7.330; 95% confidence interval: 1.384-38.809) of misunderstanding risk compared with more numerate students. CONCLUSIONS: A significant number of students at various levels of medical training lack numeracy skills, which increases misunderstanding and miscommunication of risk that can be communicated to patients and families. This deficiency could potentially affect patient safety and care.